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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200851
Report Date: 11/16/2021
Date Signed: 11/16/2021 03:24:53 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20211112145534
FACILITY NAME:SANDLEWOOD CARE HOMEFACILITY NUMBER:
019200851
ADMINISTRATOR:DIZON, LISSET RFACILITY TYPE:
735
ADDRESS:28024 SANDLEWOOD DRTELEPHONE:
(510) 940-8260
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: 5DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lisset Dizon/AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident (R1) is experiencing sexual harrassment from a staff (S1).
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with staff, Erlie Manansala and Arlan Punongbayan. LPA called and spoke with Lisset Dizon, administrator, who arrived after about an hour. LPA informed the purpose of visit.

LPA reviewed resident records and obtained copies of documents. LPA interviewed staff (S2 and S3), residents (R1, R2 and R3) and administrator and reviewed the Special Incident Report (SIR).

Administrator stated S1 has not started working here because S1 is still yet to be fingerprint cleared and associated. LPA confirmed with S2 and S3 that S1 has not worked in this facility.


.....continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20211112145534
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SANDLEWOOD CARE HOME
FACILITY NUMBER: 019200851
VISIT DATE: 11/16/2021
NARRATIVE
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All staff interviewed and 2 out of 3 residents indicated staff has not had said something that may be sexual in nature or context.

R1 indicated that when staff was assisting one of the resident in bathing, the bathroom door was open but does not think the staff intent was to harass him.

Based on all the information obtained, the allegation is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2